Initial Pediatric Gastroenterology and Nutrition Visit
Pediatric Neurology
Weill Cornell Medical Center Barry Kosofsky, MD
New York Presbyterian Hospital Chief, Pediatric Neurology
505 E 70th Street 3rd Floor
New York, NY 10021
Phone: 212-746-3278
Fax: 212-746-8137
QUESTIONNAIRE
Please complete this questionnaire. It will be an important part of your child’s medical record.
Patient Name: Today’s Date:
DOB: Age: MR #:
Name of Person Completing Questionnaire:
Relationship to Patient:
How did you learn about our practice?
Pediatrician:
Address: Telephone:
Self-Referral
Referring Physician:
Address: Telephone:
Please bring to your appointment any and all reports of previous neurological testing or consultation, or reports of significant past medical problems.
If your child ever had a brain x-ray, CT, or MRI, please borrow the films or obtain a copy of the films and bring them with you to the visit.
CHIEF COMPAINT: (Please describe the reason for your appointment.)
HISTORY OF PRESENT ILLNESS: (Please describe the problem in detail answering the following questions:
What signs or symptoms is your child experiencing?
How long have these symptoms been present?
What part(s) of the body and what functions are being affected?
How often do the symptoms occur?
Do symptoms occur at a particular time of day? If so, when?
How severe is the problem?
How long do the symptoms last?
Does anything make the symptoms get better? If so, what?
Does anything make the symptoms get worse? If so, what?
Has there been prior treatment or surgery for this problem?
PLEASE DESCRIBE ALL OTHER CURRENT MEDICAL PROBLEMS AND PAST MEDICAL ILLNESSES:
PLEASE LIST ALL PAST SURGICAL PROCEDURES WITH APPROXIMATE DATES:
CURRENT MEDICATIONS: (include over the counter, herbal therapies and vitamins).
|Medication |Dose |How often |
| | | |
| | | |
| | | |
| | | |
| | | |
Does the patient have any allergies to medications? Yes No
If yes, please list the medications and the nature of the reactions.
BIRTH HISTORY:
What was the patient’s birth weight? lbs ounces
Was the patient born prematurely? Yes No
If yes, how many weeks premature?
Were there any problems during delivery? Yes No
If yes, please describe:
Did the patient have any problems in the newborn period (first month of life)? Yes No
If yes, please describe:
How long did your child stay in the hospital after birth?
DEVELOPMENTAL HISTORY:
Have you ever had any worries about abnormal or slow development in your child? Yes No
If yes, please describe at what age you first became concerned, and what symptom(s) made you worry about development:
Has your child ever lost developmental skills? Yes No
If yes, please describe at what age the skills were lost and which skills were lost:
Has your child ever been part of any diagnosis of a specific developmental problem or handicapping condition (for example, cerebral palsy, learning disability)? Yes No
If yes, please describe:
Does your child receive any specialized developmental treatment services or special education program (for example, physical therapy or special classroom placement)? Yes No
If yes, please describe:
What is your child’s current educational placement (school, grade level)?
Family History
Has anyone in the patient’s family (or relative) had any of the following? If yes, check the box and list the person’s relationship to the patient next to the problem.
Migraine headaches Brain tumors Heart Disease
Seizures Cancer Strokes
Mental retardation Autism Psychiatric Illness
Developmental delay Attention deficit Addiction Disorders
Learning Disabilities Language Delay Genetic Disorder
Neuro-degenerative disorder Hypertension Epilepsy
Is there any other disease/illness that runs in the family?
SOCIAL HISTORY
Who lives in the same household with the patient?
|Name |Age |Relationship to the patient |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
Are the parent(s) Single Separated Married Divorced Remarried
Any unusual stresses at home or at school? Yes No
If yes, please explain.
|REVIEW OF SYSTEMS |
|Please circle “yes” or “no” for each. |
| | | | |
|GENERAL |HEAD, EARS, NOSE, MOUTH, THROAT |CARDIOVASCULAR |Gastrointestinal |
| | |Yes No | |Yes No | |Yes No | |
|Yes No |Altered taste or smell | |Large Head | |Heart defect | |Abdominal pain |
|Yes No | |Yes No | |Yes No | |Yes No | |
| |Change in appetite | |Small head | |Chest pain | |Constipation |
|Yes No |Feeding problems |Yes No | |Yes No | |Yes No | |
| | | |Abnormal Head Shape | |Chest pressure | |Diarrhea |
|Yes No | |Yes No | |Yes No | |Yes No | |
| |Poor weight gain | |Bulging soft spot | |Fainting | |Gastritis |
|Yes No |Weight loss |Yes No |Ringing in ears |Yes No | |Yes No | |
| | | | | |Heart Failure | |Food intolerance |
|Yes No | |Yes No | |Yes No | |Yes No | |
| |Unable to sleep | |Nasal discharge | |Heart Murmur | |Feeding problems |
|Yes No | |Yes No | |Yes No | |Yes No | |
| |Excessive sleepiness | |Sinus problems | |High blood pressure | |Bloody stools |
|Yes No | |Yes No | |Yes No | |Yes No | |
| |Fatigue | |Mouth sores | |Low blood pressure | |Colic |
|Yes No | |Yes No | |Yes No | |Yes No | |
| |Recurrent Fever | |Sore throat | |Shortness of breath | |Vomiting |
| |Yes No |Hearing loss |Yes No | | |
| | | | |Leg swelling | |
| | |ENDOCRINE | |
|MUSCULOSKELETAL |EYES | |RESPIRATORY |
|Yes No | |Yes No | |Yes No |Temperature instability |Yes No |Asthma |
| |Spine defects | |Blurred vision | | | | |
|Yes No | |Yes No | |Yes No |Irregular menses |Yes No | |
| |Neck pain | |Double vision | | | |Bronchitis |
|Yes No | |Yes No | |Yes No |Diabetes |Yes No | |
| |Joint pain | |Glaucoma | | | |Chronic Lung Disease |
|Yes No | |Yes No | |Yes No |Early or late puberty |Yes No | |
| |Joint swelling | |Cataracts | | | |Pneumonia |
|Yes No | |Yes No | |Yes No |Thyroid problems |Yes No | |
| |Back or neck pain | |Eye pain | | | |Tuberculosis |
|Yes No |Muscle pain | |Yes No | |
| | | | |Chronic cough |
| |URINARY | |IMMUNOLOGIC/ALLERGY |
|SKIN/HAIR | |BLOOD/LYMPH | |
|Yes No | |Yes No | |Yes No |Easy bleeding |Yes No |Immune deficiency |
| |Birth marks | |Increased frequency | | | | |
|Yes No | |Yes No |Increased urgency |Yes No |Easy bruising |Yes No |Frequent infections |
| |Skin rash | | | | | | |
|Yes No | |Yes No | |Yes No |Frequent nose bleeds |Yes No |Severe infections |
| |Brittle hair | |Delayed or Regressed toilet| | | | |
| | | |training | | | | |
|Yes No | |Yes No | |Yes No |Swollen lymph nodes |Yes No |Poor wound healing |
| |Easy scarring | |Urinary Infections | | | | |
| BEHAVIOR/PSYCHIATRIC |NEUROLOGIC |
|Yes No |Anxiety |Yes No |Difficulty Concentrating |Yes No | |Yes No | |
| | | | | |Clumsiness | |Choking |
|Yes No |Depression |Yes No | |Yes No | |Yes No | |
| | | |Vertigo | |Facial numbness | |Difficulty chewing |
|Yes No |Panic attacks |Yes No | |Yes No |Numbness (arms) |Yes No |Difficulty swallowing |
| | | |Dizziness | | | | |
|Yes No |Trouble concentrating |Yes No | |Yes No | |Yes No | |
| | | |Headache | |Numbness (legs) | |Difficulty tasting |
|Yes No |Hallucinations |Yes No | |Yes No | |Yes No |Difficulty smelling |
| | | |Lethargy | |Poor balance | | |
|Yes No |Suicidal thoughts |Yes No | |Yes No | |Yes No | |
| | | |Memory problems | |Poor coordination | |Drooling |
|Yes No |Confusion |Yes No | |Yes No | |Yes No | |
| | | |Convulsions | |Speech difficulty | |Hoarseness |
|Yes No |Personality Change |Yes No | |Yes No | |Yes No | |
| | | |Seizures | |Stiffness | |Incontinence- bowel |
|Yes No |Temper tantrums |Yes No |Syncope |Yes No | |Yes No | |
| | | | | |Trouble walking | |Incontinence- bladder |
|Yes No |Withdrawn behavior |Yes No | |Yes No | |Yes No | |
| | | |Sleep problems | |Weakness (arms) | |Pain |
|Yes No |Aggressive behavior |Yes No |Blurred vision |Yes No | |Yes No | |
| | | | | |Weakness (legs) | |Abnormal movements |
|Yes No |Inattention |Yes No |Double vision |Yes No |Tremor | |
|Yes No |Hyperactive | | | | | |
|Yes No |Impulsive | | | | | |
Other Symptoms (please describe):
X
Parent/Guardian/Patient Signature Date
X
Physician Signature Date
Please return this questionnaire to pedsneurotele@med.cornell.edu prior to the doctor’s visit.
Race and Ethnicity Information
We want to make sure that all our patients get the best care possible. We would like you to tell us your child’s racial and ethnic background as well as your preferred language so that we can review the treatment that all patients receive and make sure that everyone gets the highest quality of care. You may decline to answer if you wish.
The only people who see this information are registration staff, administrators for the practice, your care providers, and the people involved in quality improvement and oversight, and the confidentiality of what you say is protected by law.
Please mark the appropriate response:
Primary Language
Albanian American Sign Language Arabic Armenian
Bengali Bosnian Cantonese (Chinese)
Creole Croatian ECH Danish
English French German Greek
Hebrew Hindi Indonesian Italian
Japanese Korean Latin Malay
Mandarin (Chinese) Persian Polish
Portuguese Romanian Russia Serbian
Slovak Spanish Swahili Swedish
Tagalog Thai Turkish Urdu
Vietnamese Yiddish Yugoslavian Other
Declined Unknown
Race
American Indian or Alaska Native Asian
Black or African American Native Hawaiian or Other Pacific Island
White Other Combination Not Described
Declined
Ethnicity
Hispanic or Latino or Spanish Origin
Not Hispanic or Latino or Spanish Origin
Declined
Pharmacy Information
So that you and your physician may take advantage of e-prescribing, we need you to provide information on the pharmacy that you choose to use to fill you or your child’s prescriptions. Electronic prescription requests are more efficient, accurate and cost effective. Feel free to speak with your physician if you have additional questions.
New
Date:
Patient Name:
NYH #:
PRIMARY
Pharmacy Name:
Address:
Phone Number:
Fax Number:
SECONDARY (if applicable)
Pharmacy Name:
Address:
Phone Number:
Fax Number:
................
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